AI Frontier Institute

A bill for an act relating to utilization review organizations' use of artificial intelligence, prior authorization determinations and exemptions, and audits, and including applicability provisions.(Formerly SSB 3118.)

View primary source →

Iowa Senate File 2421 regulates how utilization review organizations (UROs) use artificial intelligence in prior authorization decisions, establishes peer-review requirements for denials, creates prior authorization exemptions for cancer screenings and life-threatening conditions, and sets timelines for prepayment audits. Division I (Sections 1–4) amends Section 514F.8 and adds new Section 514F.8A: UROs may use AI algorithms for initial review of prior authorization requests, but AI alone cannot be the sole basis for denying, delaying, or downgrading a medically-necessary service request. Denials or downgrades must be made by a 'qualified reviewer' (a physician in the same specialty) if the requesting provider is a physician, or a 'clinical peer' (a same-specialty health care professional) otherwise. UROs must provide written reasons, appeals-process explanations, and written attestations of reviewer qualifications. Within seven business days of a denial, the URO must conduct a consultation between the provider and a qualified reviewer or clinical peer. Appeals must be handled by a different qualified reviewer or clinical peer than the one who made the initial decision. Division II (Sections 5–6) adds Section 514F.8B: health carriers cannot require prior authorization for cancer-related screenings recommended under the most recently updated National Comprehensive Cancer Network clinical practice guidelines in oncology. Division III (Sections 7–8) adds Section 514F.8C: health carriers cannot require prior authorization for diagnosis and treatment of a life-threatening condition that arises while a covered person is already receiving inpatient treatment. Division IV (Sections 9–10) adds Section 514F.10: when a URO or carrier audits a claim, it must notify the provider within 15 calendar days of selecting the claim, complete the audit and issue a determination within 45 calendar days of receiving all documentation, and resolve appeals within 14 calendar days of receiving notice of appeal. Providers have 30 calendar days to appeal an adverse audit determination. If a carrier or URO violates these audit timelines, the claim is automatically approved and promptly paid. Most provisions apply to plans and requests on or after January 1, 2027, with some retroactive application to pending requests.

← Back to the tracker